Medicaid Prior Authorization and Discontinuation of Buprenorphine

Buprenorphine is effective in reducing opioid-related overdose, yet many patients discontinue prematurely. Little is known regarding the influence of utilization management policies on buprenorphine discontinuation. This study assesses the duration of buprenorphine episodes paid by fee-for-service (FFS) and managed care organization (MCO) plans with and without prior authorization (PA) in Medicaid.

Cross-sectional analysis was conducted using 2018 national prescription claims data with 810,449 treatment episode months involving dispensed buprenorphine prescriptions with an FDA-approved indication for opioid use disorder treatment reimbursed by Medicaid. Standard discrete-time survival models using logistic regression were conducted to examine differences in duration to buprenorphine discontinuation in months by reimbursement type.

Buprenorphine continuation decreased over time across all Medicaid insurance types; this decline was slightly sharper for episodes paid for by MCO plans with PA. The adjusted survival for buprenorphine treatment for 12 months was statistically significantly (P < 0.01) lower for episodes among enrollees in MCO plans with PA (21.6%) compared with episodes paid for by FFS with PA (22.5%); it was also lower in MCO plans without a PA (22.7%) compared with FFS without a PA (23.1%).

Buprenorphine discontinuation was high across all treatment episodes, with few differences across Medicaid plan arrangement type or PA status. The sharpest declines in buprenorphine continuation were observed across all types within the first 3 months of the episode starting, highlighting an important period to target buprenorphine continuation improvements. Future research is needed to explore other insurer policies, like concurrent reviews and quantity limits, which may also influence discontinuation.